Perforated peptic ulcer is managed surgically by simple closure with an omental patch (Graham patch). Which is the correct indications/contraindications balance for adding a definitive anti-ulcer procedure (e.g., truncal vagotomy + pyloroplasty) at the time of emergency laparotomy?

• A All patients with perforation should have a definitive anti-ulcer procedure added to reduce recurrence
• B Definitive surgery should be added in all haemodynamically stable patients regardless of H. pylori status
• C Truncal vagotomy is mandatory in patients on NSAIDs to prevent recurrence
• D In the H. pylori/PPI era, simple patch closure followed by H. pylori eradication and PPI is as effective as definitive surgery; adding vagotomy is now rarely justified ✓

Explanation

In the modern era of effective H. pylori eradication and PPIs, simple Graham patch closure followed by H. pylori testing/treatment and PPI provides a recurrence rate (<5%) equivalent to definitive surgery, without the added morbidity of vagotomy in an emergency setting. Definitive anti-ulcer surgery (truncal vagotomy + pyloroplasty or drainage) is now rarely performed at emergency laparotomy. Exceptions include haemorrhage or obstruction requiring reconstructive surgery, or failure of prior H. pylori eradication.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.